Good afternoon, colleagues. First of all, I'd like to thank the Society for the opportunity to speak to you today, but more importantly, I would like to thank members of the Surgery Section, and particularly the leaders. Many of them are here today, as well as members of the Surgery Section's Education Committee. I see a lot of familiar faces. This presentation represents the culmination of hard work by a lot of very talented and enthusiastic individuals who serve as leaders in their homes. And so I'd just like to thank all of them. I've chaired this committee for three years. It's been a real pleasure and an honor, so thank you. I have one disclosure, which is that I'm an up-to-date author on topics relevant to critical care. I'd like to begin with sepsis. So the RAW group is a working group out of the Eastern Association for the Surgery of Trauma, who performed a systematic review and meta-analysis on the duration of antibiotics after definitive source control for complex intra-abdominal infection. They reviewed 16 studies, and they defined a short duration of therapy as four days on average, and a long duration of therapy as eight days on average. They found, when they compared the two, that there were no differences between short and long duration of antibiotic therapy in terms of mortality, surgical site infection, or persistent or recurrent infection. And based on these findings, they recommended a shorter duration of therapy, four days or less, in the setting of complex intra-abdominal infection when definitive source control has been achieved. The next paper on the topic of shock and vasopressors is my personal top favorite article for 2023. By the way, my personal favorites are based largely on applicability to real-world practice. Is this a good study? Has it been done well? Can I apply it to my practice? Is it useful? And so this is my favorite paper of the year. The SHU group investigated the timing of vasopressin initiation in patients with septic shock. They performed a retrospective observational cohort study of 1,817 patients who had septic shock. Patients were stratified into either a low-dose norepinephrine group or a high-dose. When vasopressin initiation was introduced at low doses of norepinephrine, patients had a reduced 28-day mortality, they received significantly shorter durations of norepinephrine, less IV fluids, and they made more urine and enjoyed more vent-free days. Transfusion. The Carson group published guidelines on transfusion thresholds in patients with anemia. They reviewed 45 randomized controlled trials, including over 20,000 patients, and compared restrictive practices for transfusion to liberal ones. They recommended, in keeping with TRIC trial recommendations, a threshold of 7 for transfusing hemodynamically stable patients. In the case of operative patients, they recommended a threshold of 7.5 for cardiac surgery and a threshold of 8 for orthopedic surgery when preexisting cardiovascular conditions were at play. The Rho group performed a very interesting study of how hemoglobin concentration impacts viscoelastic factors and other kinetics associated with coagulation using Rhotem or Teg. They performed an observational multicenter cohort study of ICU patients, and they found that the hemoglobin concentrations directly correlated with Rhotem and Teg coagulation kinetics and inversely correlated with clot strength. So based on this, they concluded that although patients with a low hemoglobin may appear to have normal coagulation parameters by traditional testing, in fact, they actually have a mild hypocoagulable state. On the topic of venous thromboembolism, there were a number of papers that came out this year looking at the timing of initiation of chemoprophylaxis, and this was my favorite. There were two competing papers with similar outcomes for intracranial bleed and also blunt solid organ injury. The Schellenberg group performed a study with the aim to determine the optimal time to initiate chemoprophylaxis after blunt solid organ injury. Nineteen participating trauma centers in North America included patients with liver, spleen, or kidney injury. They defined the two groups of study, patients who received therapy before 48 hours after admission and patients who received it after 48 hours. They included 1,173 patients, and what they found was that patients who received early prophylaxis had significantly lower rates of venous thromboembolism. They also had lower rates of transfusion after prophylaxis. The late group was associated with a higher rate of VTE, and so based on these findings, the investigators recommended the initiation of therapy within 48 hours of admission after blunt solid organ injury because it's safe, it's effective, and they felt it should be the standard of care. Anticoagulation and antifibrinolysis. The ProCoag group, which was led by Bouzat, aimed to investigate the efficacy and safety of four-factor prothrombin complex concentrate administration to patients at risk for massive transfusion. In this double-blind, randomized placebo-controlled superiority trial, which was performed in 12 French intensive care units, 324 trauma patients were randomized to receive either four-factor PCC or saline placebo. Among the patients with trauma at risk for massive transfusion, there was no significant reduction in 24-hour blood product consumption after the administration of PCC. Those patients did have a higher rate of thromboembolic events as well. The Lipsky group aimed to look at four-factor PCC compared with andexanet alpha for the reversal of new oral anticoagulants, like apixaban and rivaroxaban, in the setting of intracranial hemorrhage. They found that the rate of effective hemostasis was similar in the patients who received PCC as well as andexanet alpha. They found no statistically significant difference in secondary outcomes like 28-day mortality or thrombotic complications. And so based on these findings, they recommend using either drug because they both have similar excellent or good rates of hemostatic efficacy. On the topics of fluids and resuscitation, one of my personal favorites, comes my number two paper of the year by the Shapiro group. They performed an unblinded superiority trial in 60 U.S. centers. They randomized patients to receive either a restrictive fluid protocol or a liberal one for the first 24 hours of their hospital stay. The restrictive group had earlier, more prevalent, and longer duration of vasopressor use. The number of serious reported adverse events were similar in the two groups. And so the authors concluded that a restrictive fluid strategy did not result in significantly lower or higher mortality. Abdominal catastrophe. The PENGRMA group looked at long-term outcomes for patients with acute mesenteric ischemia. They performed a retrospective study of 66 consecutive patients who were treated with acute mesenteric ischemia. Using an endovascular intervention first strategy, 44 patients, 88%, successfully were treated. And three of those patients were ultimately, sorry, ultimately needed to undergo open revasc. One third of them required a bowel resection before they were the end of 30 days. By 30 days, 32% of the patients who received endovascular therapy first had died, whereas 81% of patients who did not receive endovascular therapy first had died. Based on this finding, it is very encouraging that patients should have endovascular therapy first, but by five years, the survival rates were almost the same, 18 and 13%. Acute kidney injury and kidney failure. The GILES group aimed to determine whether or not repeat contrast loads in trauma patients contributed to acute kidney injury and kidney failure. In this eight-year retrospective study, adult ICU patients with an injury severity score of 15 or higher were included. 663 multiply injured patients who received repeated contrast studies were evaluated. The incidence of acute kidney injury was 13%, and contrast-induced acute kidney injury was only 14%. Multivariate analysis revealed that receiving additional contrast doses within the first 72 hours of admission was not associated with acute kidney injury. Based on these findings, the authors concluded that while there is a limited role of repeat contrast loads in acute kidney injury, the overall significance of contrast-induced acute kidney injury is likely overestimated, and that should not compromise essential imaging in intensive care unit patients. Liver failure, liver failure. The NONSHELL group reported guidelines on the management of adult patients with acute or acute-on-chronic liver failure in the ICU. For those of you who attended the presentation yesterday, it was a very nice review. These authors, 27 experts who formed a guidelines panel, conducted a systematic review and meta-analysis, and they identified 28 recommendations for managing these patients. Heart failure, ECMO, and cardiac surgery. The ECMO-CS investigator group aimed to compare the immediate implementation of a VA ECMO intervention versus initial conservative therapy in patients with rapidly deteriorating or severe cardiogenic shock. In this multicenter randomized trial, patients were randomized to VA ECMO or supportive care. The composite primary endpoint was death, and it occurred in 63% of patients who received ECMO. It occurred in 71% of patients who were treated with supportive care, but it was not a significant difference. Based on this finding, authors recommended that the implementation of a VA-first approach did not improve clinical outcomes compared with an early conservative strategy. Asteroid failure and ARDS. In this very interesting trial, the Landis group compared continued enteral nutrition through the time of extubation with a traditional six-hour fasting prior to extubation. Patients undergoing mechanical ventilation and enteral feeds were randomly assigned to receive either continued feeds through extubation or a six-hour fast. The primary outcome was extubation failure at seven days. They found extubation failure occurred in 17% of patients in both groups. The rate of pneumonia within 14 days was very low, 1% and 2%. Based on these findings, they recommend that continued enteral nutrition through extubation is non-inferior to a traditional six-hour fast. Brain death and brain injury. The Greer group published updated guidelines on adult brain death and death by neurologic criteria based on the findings of an expert panel from multiple medical societies. And they made 85 recommendations, which I'm going to read to you right now. Just kidding. I couldn't resist. Adrenal insufficiency. The Abdelrahim group reported their findings on the prognostic value of a low-dose ACTH stem study in critically ill patients. In previous trials, a much higher dose for a stem test was used in an attempt to identify corticosteroid insufficiency, or SIRSI. Investigators aimed to determine if the incidence of SIRSI in septic patients was something they could identify with a lower dose because they felt that the higher dose sometimes contributed to false positive results. In their study, using the one-microgram dose, the primary outcome was death. The incidence of SIRSI in their cohort was 43%. There was no difference in terms of secondary outcomes. The SIRSI group had a lower median survival, and they had a higher incidence of acute kidney injury. Based on these findings, they felt that their one-microgram lower-dose test was helpful in identifying the subgroup of patients who were at risk for poor outcomes. Hemodynamics, devices, and monitoring. This is my number four paper of the year, and in case you're wondering, there is a number three. It's coming. This group aimed to determine whether targeting a higher MAP goal with vasopressors compared to a lower goal improved patient outcomes. They performed a random, excuse me. They reviewed six randomized trials and identified 3,690 patients who met criteria. Targeting the higher MAP of 75 to 85 compared with the lower MAP goal of 65 resulted in no difference in mortality. Targeting a higher MAP also resulted in no difference in undergoing renal replacement therapy. Based on these findings, they could not recommend titrating pressors to a higher MAP. Point of care ultrasound. The Yoshida group aimed to evaluate the diagnostic accuracy of POCUS in identifying the etiology of shock. They performed a systematic review of 12 studies and 1,132 patients. They looked at the pooled sensitivity and specificity for obstructive shock, cardiogenic shock, hypovolemic shock, and distributive shock. They found that the identification of the etiology of each type of shock used using POCUS was characterized by a high sensitivity and specificity, especially in the setting of obstructive shock. Nutrition. This is my number five paper of the year. The Kagan group studied a new feeding platform called SMART+. SMART+, was able to monitor patient feedings in effort to reach daily targets more efficiently than traditional feeding protocols. The primary out point in this study was average deviation from the daily nutritional target. The SMART group of patients achieved a mean deviation from the daily target of only 10%. And that was compared to a 34% rate of deviation in the traditional feeding group. SMART+, patients had a shorter length of stay and they had fewer vent days. The feeding goals were ultimately met on 75% of days for patients on the SMART+, platform, but only 23% of the time with traditional feeding protocol. There were no treatment related adverse events in either group. So based on this, the study was actually ended early and the authors recommended the SMART+, platform because it improved adherence to feeding goals, reduced length of stay and also length of the vent. Pain and sedation. The Kotani group studied etomidate as an adduction agent for endotracheal intubation in critically ill patients. And in this meta-analysis of 11 randomized trials and 2,704 patients, they found that etomidate increased mortality. Multi-organ dysfunction. The Ting group aimed to look at multi-organ dysfunction in trauma patients. As many of you know, post-injury multi-organ failure is the leading cause of late death in trauma patients. They found that multiple organ failure incidents was reported in 284 studies with 11 unique inclusion criteria and 40 different definitions. They found four different scoring systems that were used in these different research trials. So based on their review of 351,000 trauma patients, they identified a rate of multi-organ failure of 24%, but they noted that the incidents varied so widely depending on different definitions and there was no consensus in terms of definitions that it was very difficult to perform good research on this topic. Rehabilitation. The Jenkins group looked at how rehabilitation impacts patient outcomes after critical illness. They performed a retrospective study of 6,000 patients who received PT across multiple sites and states. Very interesting. A regression analysis showed that for every 10 minutes of PT or OT that a patient received each day, it was associated with a 1% higher final basic mobility score, a 1.82% higher final daily activity score, and a 1.1 day lower length of stay. They also found an exponential decrease in the predicted length of stay as the minutes of PT or OT increased. So based on this finding of higher rehabilitation minutes, translating into improved patient outcomes, they found that the benefits of rehab increased with increasing amounts of therapy, not surprisingly. With that, I would like to say thank you very much for your attention and have a nice afternoon.

critical care studies

antibiotics duration

vasopressin in septic shock

transfusion thresholds

chemoprophylaxis post-injury